in details

1. INFLAMMATORY BOWEL
DISEASE
By : dr. mahmoud alao
(( Pediatric resident ))
Supervised by :
dr. Jafar alaјlony
(( pediatric specialist ))

2. Inflammatory bowel disease (IBD) :
Is a term used to represent tow distinctive
disorders of idiopathic chronic intestinal
inflammation
These disorders are :
Crohn disease and Ulcerative colitis

3. - A 3rd, less-common category, Indeterminate colitis,
represents ∼10% of pediatric patients

4. In general , inflammatory bowel disease
characterized by :
- Poorly understood etiologies
- Unpredictable exacerbations and remissions
- Onset in preadolescent/adolescent or early
adulthood

5. - About 25% of patients present before 20 years of
age
- IBD may begin as early as the 1st year of life

6. Etiology and pathogenesis
The exact cause is unknown but there is a
contributing or associated factors :
- Genetic factors
- Immunological factors
- Environmental factors

7. Genetic factors :
- NOD2 , the first identified associated gene

8. - HLA DR2 related genes are associated with ulcerative
clolitis
- HLA DR5 related genes are associated with chron
disease

9. - If one family member is affected the risk is
))(( 7-30 %
- if both parents are affected the risk is
(( more than 35 % ))

10. Immunological factors
- Defective regulation of immunesuppression
( defective physiologic inflammatory response )
- A perinuclear antineutrophil antibody (pANCA) is
found in ∼70% of patients with ulcerative colitis
compared with <20% of those with Crohn disease

12. Environmental factors :
- IBD is more common in developed contries
- Cigarette smoking is a risk factor for Crohn disease
but paradoxically protects against ulcerative colitis
- No single infectious agent is reported

14. PATHOLOGICAL FEATURES
- MACROSCOPIC
- MICROSCOPIC

15. Ulcerative colitis
( macroscopic features )
• Affect the rectum and colon
• Affect the inner lining
• Spread in continuity
• Superficial ulcers and pseudopolyps

17. Crohn disease
( macroscopic features )
• Can affect any part of the GIT
• Transmural
• Segmental with skip lesions
• Cobblestone appearance

18. Ulcerative colitis
( microscopic features )
• Cryptitis and crypt abscesses
• Superficial erosions
• Crypt separation by inflammatory cells with foci of
acute inflammation
• Branching of crypts

19. Crohn disease
( microscopic features )
• Aphthous ulceration
• Focal crypt abscesses
• Submucosal and subserosal lymphoid aggregates
• Transmural with fissure formation

20. Presentation and clinical features

21. - It is usually possible to distinguish between ulcerative
colitis and Crohn disease by the clinical presentation
and radiologic, endoscopic, and histopathologic
findings

22. - It is not possible to make a definitive diagnosis in ∼10%
of patients with chronic colitis; this disorder is
called indeterminate colitis

23. - Occasionally, a child initially believed to have
ulcerative colitis on the basis of clinical findings is
subsequently found to have Crohn colitis : This is
particularly true for the youngest patients, because
Crohn disease in this patient population can more often
manifest as exclusively colonic inflammation,
mimicking ulcerative colitis

24. Intestinal symptomes in ulcerative colitis
- Blood, mucus, and pus in the stool as well as diarrhea
are the typical presentation of ulcerative colitis
- Tenesmus, urgency, cramping abdominal pain
(especially with bowel movements), and nocturnal
bowel movements are common
- The mode of onset ranges from insidious with gradual
progression of symptoms to acute and fulminant

25. Fulminant colitis
- Fever
- severe anemia
- Hypoalbuminemia
- Leukocytosis
- More than 5 bloody stools per day For 5 days

26. Intestinal symptomes in crohn disease
- Patients with small bowel disease are more likely to
have an obstructive pattern (most commonly with
right lower quadrant pain) characterized by
fibrostenosis
- Patients with colonic disease are more likely to have
symptoms resulting from inflammation (diarrhea,
bleeding, cramping)

27. - In contrast to ulcerative colitis, perianal disease is
common (tags, fistula, abscess)
- Gastric or duodenal involvement may be associated
with recurrent vomiting and epigastric pain
- Partial small bowel obstruction, usually secondary to
narrowing of the bowel lumen from inflammation or
stricture, can cause symptoms of cramping abdominal
pain (especially with meals), borborygmus, and
intermittent abdominal distention

29. - Systemic signs and symptoms are more common in
Crohn disease than in ulcerative colitis. Fever, malaise,
and easy fatigability are common
- Growth failure with delayed bone maturation and
delayed sexual development can precede other
symptoms by 1 or 2 yr and is at least twice as likely to
occur with Crohn disease as with ulcerative colitis

30. Children can present with growth failure as the only
manifestation of Crohn Disease
Causes of growth failure include :
- Inadequate caloric intake
- Suboptimal absorption or excessive loss of nutrients
- The effects of chronic inflammation on bone metabolism and
appetite
- The use of corticosteroids during treatment

31. Extraintestinal manifestations in ulcerative colitis
• pyoderma gangrenosum
• sclerosing cholangitis
• chronic active hepatitis
• ankylosing spondylitis

32. Extraintestinal manifestations in crohn disease
• oral aphthous ulcers
• peripheral arthritis
• erythema nodosum
• digital clubbing
• episcleritis
• renal stones (uric acid, oxalate)
• gallstones

35. Can a patient has both diseases
together ???

36. No

37. So ,
What is the indeterminate colitis
???????????

38. - In indeterminate colitis the disease is confined to the
colon but it may be showing characteristics of both
diseases that make it hard to make a definite
diagnosis
- So , patients with indeterminate colitis may stay with
this entity or develop crohn disease or ulcerative
colitis later on

39. - If the patient has small bowel affection , the diagnosis
is crohn disease because indeterminate colitis is a term
used for non specific inflammation with mixed features
of both ulcerative colitis and crohn disease when
occurred in the colon only

40. Diagnosis
- Laboratory
- Barium and radiological studies
- Endoscopy
- Biopsy

41. Note :
In case of ulcerative colitis , if symptomes
are suggestive and the duration is less
than 3 weeks , infection must be excluded
before diagnosis

42. Infections in the differential diagnosis :
- Campylobacter jejuni
- Yersinia enterocolitica
- Clostridium difficile
- Shigella
- Entamoeba histolytica
- Giardia lamblia

43. Laboratory findings :
- Elevation of inflammatory markers :
- CRP
- ESR
- Platelets
- leukocytes

44. - Anemia either due blood loss or anemia of chronic
disease
- Hypoalbuminemia
- Fecal calprotectin levels are usually elevated

45. Barium enemas and radiological studies
- In ulcerative colitis its not diagnostic but suggestive
and shows :
- fine mucosal granularities
- superficial ulcers
- pipe stem appearance due loss of haustrations

47. - In crohn disease radiologic studies are necessary for
the entire GI tract ,,, plain films , enemas and contrast
small bowel follow through may show :
- Ulceration
- Narrowing
- Stricturing

49. - In Crohn disease CT and MR enterography and small
bowel ultrasound are increasingly being used to
assess for intestinal wall thickening and extraluminal
findings such as abscesses or fistulas

50. Endoscopy and biopsy
- Can establish the diagnosis
- Estimate the stage and severity of the
disease
- Delinate the treatment options

53. Treatment
1-medical
2- surgical
3- support

54. Medical

55. Ulcerative colitis
- A medical cure for ulcerative colitis is not available;
treatment is aimed at controlling symptoms and
reducing the risk of recurrence
- About 20-30% of patients have spontaneous
improvement in symptoms
- Most children are in remission within 3 mo; however, 5-
10% continue to have symptoms unresponsive to
treatment beyond 6 mo

56. Crohn disease
- The specific therapeutic modalities used depend on
geographic localization of disease, severity of
inflammation, age of the patient, and the presence of
complications (abscess)
- Antibiotics such as metronidazole are used for
infectious complications and are first line therapy for
perianal disease

57. - Unfortunately, up to 50% of children with Crohn
disease either become refractory to corticosteroid
therapy or become dependent on daily dosing and
quickly experience flare of the disease when the dose
is decreased

58. Drugs used in both diseases :
1- aminosalicylates ( 5-ASA )
- sulfasalazine ( 50-75 mg/kg/24 hr )
Because of poor tolerance and hypersensitivity ,
sulfasalazine is used less commonly than other, better
tolerated preparations (mesalamine, 50-100 mg/kg/day;
balsalazide 110-175 mg/kg/day)

59. - These preparations have been shown to effectively
treat active ulcerative colitis and to prevent recurrence.
- It is recommended that the medication be continued
even when the disorder is in remission.
- These medications might also decrease the lifetime risk
of colon cancer

60. - Approximately 5% of patients have an allergic reaction
to aminosalicylates , manifesting as rash, fever, and
bloody diarrhea, which can be difficult to distinguish
from symptoms of a flare of ulcerative colitis
- Hypersensitivity to the sulfa component is the major
side effect of sulfasalazine and occurs in 10-20% of
patients

61. - Aminosalicylates can also be given in enema or
suppository form and is especially useful for proctitis
- Oral and rectal 5-ASA has been shown to be more
effective than just oral 5-ASA for distal colitis

62. 2- Probiotics
- Probiotics have been shown to be effective in adults
for maintenance of remission for ulcerative colitis,
although they have not been shown to induce
remission during an active flare
- The most promising role for probiotics has been to
prevent pouchitis, a common complication following
surgery

63. - The efficacy of probiotics in treatment of
Crohn disease is controversial

64. 3- corticosteroids
- most commonly, oral prednisone : 1-2 mg/kg/24 hr (40-
60 mg maximum dose)
- moderate to severe pancolitis or colitis that is
unresponsive to 5-ASA therapy
- With severe colitis, the dose can be divided twice daily
and can be given intravenously

65. - Steroids are considered an effective medication for
acute flares, but they are not appropriate maintenance
medications due to loss of effect and side effects
- Steroids have not been shown to change disease
course or promote healing of mucosa

66. - Budesonide, a corticosteroid with local anti-
inflammatory activity on the bowel mucosa is also used
for mild to moderate ileal or ileocecal disease
- More effective than mesalamine in the treatment of
active ileocolonic disease but is less effective than
prednisone
- Although less effective than traditional
corticosteroids, it cause less steroid-related side effects

67. Hydrocortisone enemas are used to treat proctitis but
they are probably not effective as 5-ASA

68. Steroids side effects include :
- Growth retardation
- Adrenal suppression
- Cataracts
- Osteopenia
- Aseptic necrosis of the head of the femur
- Glucose intolerance
- Risk of infection

69. 4- Immunomodulators
- Most commonly azathioprine (2.0-2.5 mg/kg/day) or
6-mercaptopurine (1-1.5 mg/kg/day)
- Less commonly cyclosporine (which has been
associated with improvement in some children with
severe or fulminant colitis ) or thiopurine
- For children with disease resistant or requiring
frequent corticosteroid therapy

70. Methotrexate is another immunomodulator that is
effective in the treatment of active Crohn’s disease and
has been shown to improve height velocity in the 1st
year of administration.
- The advantages include once-weekly dosing by either
subcutaneous or oral route and a more-rapid onset of
action (6-8 wk) than azathioprine or 6-mercaptopurine.
- Folic acid is usually administered concomitantly to
decrease medication side effects

71. Side effects of immunomodulators include :
- Flu-like symptoms
- Bone marrow suppression
- Liver and lung inflammation
- Lymphoproliferative disorders mainly from thiopurine

72. 5- Anti tumor necrosis factor antibodies
- Most commonly Infliximab (5 mg/kg IV)
- The use of anti-TNFs in UC has demonstrated efficacy
in achieving steroid-free remission and mucosal healing,
and in changing the natural history (colectomies)

73. - Infliximab has been shown to be effective for induction
and maintenance therapy in patients with moderate to
severe disease
- Infliximab is also effective in cases of fulminant colitis

74. - Infliximab has increasing use in moderate to severe
disease in patient with failure of steroid and
immunomodulators and in case of steroid refractory
severe acute UC
- Infliximab has impact on natural history of the disease
by decreasing the colectomy rates

75. - The onset of action of infliximab is quite rapid and it is
initially given as 3 infusions over a 6 wk period (0, 2,
and 6 wk)
- The durability of response to infliximab is variable and
can be as short as 4-8 wk, making maintenance therapy
necessary

76. Side effects of infliximab include :
- Infusion reactions
- Increased incidence of infections (especially
Reactivation of latent tuberculosis)
- Increased risk of lymphoma
- The development of autoantibodies and autoimmune
disorders (leukocytoclastic vasculitis)

77. - A purified protein derivative (PPD) test for
tuberculosis should be done before starting infliximab
- Active or latent intra-abdominal infection (abscess) is a
contraindication to infliximab therapy

78. Diet therapy in crohn disease

79. Exclusive enteral nutritional therapy
( elemental or polymeric diets )
- The use of a complete liquid diet, with the exclusion of
normal dietary components for a defined period of
time, as a therapeutic measure to induce remission in
active Crohn disease , Is an effective primary as well as
adjunctive treatment
- Because elemental diets are relatively unpalatable,
they are administered via a nasogastric or gastrostomy
infusion, usually overnight

80. - This intervention also results in mucosal healing,
nutritional improvements and enhanced bone health
- Children can participate in normal daytime activities
- A major disadvantage of this approach is that patients
are not able to eat a regular diet , In addition, perianal
and colon disease does not respond well
- For children with growth failure, this approach may be
ideal

81. High-calorie oral supplements
- Although effective , are often not tolerated because of
early satiety or exacerbation of symptoms (abdominal
pain, vomiting, or diarrhea)

82. Surgical

83. Ulcerative colitis
Colectomy is performed for :
- Intractable disease
- Complications of therapy
- Fulminant disease that is unresponsive to medical
management

84. - The major complication of this operation is pouchitis
( is seen in 30-40% ) , which is a chronic inflammatory
reaction in the pouch, leading to bloody diarrhea,
abdominal pain, and, occasionally, low-grade fever ,
treatment is with oral metronidazole or ciprofloxacin

85. Crohn disease
- Surgical therapy should be reserved for very specific
indications
- Recurrence rate after bowel resection is high (>50% by
5 yr); the risk of requiring additional surgery increases
with each operation

86. Surgery is the treatment of choice for :
- Localized disease of small bowel or colon that is
unresponsive to medical treatment
- Bowel perforation
- Fibrosed stricture with symptomatic partial small
bowel obstruction
- Intractable bleeding

87. Potential complications of surgery include :
- Development of fistula or stricture
- Anastomotic leak
- Postoperative partial small bowel obstruction
secondary to adhesions
- Short bowel syndrome

88. Support

89. - Psychosocial support is an important part of therapy
for this disorder
- This may include adequate discussion of the disease
manifestations and management between patient and
physician, psychological counseling for the child when
necessary, and family support from a social worker or
family counselor

90. Prognosis

91. Ulcerative colitis
- The course of ulcerative colitis is marked by
remissions and exacerbations
- Most children with this disorder respond initially to
medical management

92. - Beyond the 1st decade of disease, the risk of
development of colon cancer begins to increase rapidly.
The risk of colon cancer may be diminished with
surveillance colonoscopies beginning after 8-10 yr of
disease

93. Crohn disease
- Crohn disease is a chronic disorder that is associated
with high morbidity but low mortality
- Symptoms tend to recur despite treatment and often
without apparent explanation
- Up to 15% of patients with early growth retardation
secondary to Crohn disease have a permanent decrease
in linear growth

94. - Resection of terminal ileum can result in bile acid
malabsorption with diarrhea and vitamin
B12 malabsorption
- The risk of colon cancer in patients with long-standing
Crohn colitis approaches that associated with ulcerative
colitis, and screening colonoscopy after 10 years of
colonic disease is indicated

95. Thank you